Monday, May 20, 2013

Bomet, Kenya

By: Charles Lehmann

For my trip I elected to visit a mission hospital named
Tenwek Hospital located about 10 kilometers outside of Bomet, Kenya.
Bomet is a small Kenyan village located about a four hour drive west of
the capital Nairobi on the far side of the rift valley. Tenwek serves as
the primary hospital for approximately 600,000 people living in many small
villages and farms within a 30 kilometer radius of the hospital. It also
serves as a referral center for a much larger radius. The majority of the
people in this area are a native Kenyan tribe called the Kipsigis.

I chose to travel to Tenwek Hospital because there is a United States trained
orthopedic surgeon who works at this hospital as a full time missionary
surgeon. I wanted to experience not only what orthopedics is like in the
third world, but also what the life of a missionary surgeon is like. On Saturday, January, 26th I
arrived at Jomo Kenyatta International Airport in Nairobi, Kenya.It was already dark, but thankfully, the
driver that Samaritan’s purse had arranged to pick me up was waiting for me
immediately after I had obtained my luggage.He drove me to the Mennonite missionary guest house where I was able to
obtain a hot shower and get a reasonable night’s sleep before making the trek
to Tenwek Hospital.

The next morning a driver met me and we departed for Tenwek
Hospital. It was a fairly smooth trip by third world standards complete
with cattle crossing the highway at numerous points, police officers standing
on the edge of the road with machine guns, and a few random roadside baboons
and zebras. After arriving at Tenwek I was given a warm welcome and tour
of the hospital and grounds by the orthopedic surgeon that I was going to be
working with named Dan Galat. I quickly realized that it was going to be
a busy two weeks since the orthopedic service had greater than 40 inpatients on
it and ran 2-3 operating rooms every day during the week.

Similar to the United States we started the day out with
inpatient resident rounds at 6am. However, prior to starting rounds we
had a fairly quick devotional led by one of the residents. Following
resident inpatient rounds we met with the orthopedic attending surgeons and reviewed
the x-rays of all of the consults that had come in over the weekend and cases
that had been done.This was performed
on a small computer monitor.(Yes, they do
have digital x-rays in the third world.)Then the entire team proceeded to make other set-of rounds on all of the
orthopedic patients that were scattered throughout the hospital complex.It was remarkably similar to rounds at
Washington University other than that we stopped to pray for patients three
different times throughout rounds.

After rounds we headed to the operating rooms to start our
first case. We had two operating rooms that were filled with cases.The spinal’s had already been performed when
we arrived and the patients were in the process of being positioned for surgery.The majority of the OR staff were Kenyan
natives, but thankfully all of them spoke reasonably good English making
communication much easier. In the
room that I was placed, the first case was labeled AMP. I assumed that we
were going to be amputating somebody’s leg, however I was completely
wrong.AMP stood for Austin Moore
Prosthesis (non-cemented, non-modular hip prosthesis – this was one of the
original arthroplasty options used some 30-years ago in the United States).
Apparently, this is the cheapest hemiarthroplasty that one can buy (costs
$80 from India). Therefore, working with my mentor Dr. Galat I implanted
my first ever AMP. Another interesting part of my 1st case was that while
removing the femoral head, I noticed tumor appearing material in the femoral
canal suggesting a pathologic process. I asked if we should send this to
pathology to have it evaluated. However, I was told not to because this
patient was sick and elderly. Apparently, even if we were able diagnose a
specific cancer, the patient would not be able to afford chemotherapeutic
medications nor would was their oncologic care that would be readily accessible
to them. Obviously, a very different perspective from how we practice in
the United States.

The second case was a type I open fracture of the
tibia and fibula. We fixed it with a special kind of nail called a SIGN
nail. This is a special stainless steel intramedullary nail designed by a
guy in the United States specifically for use in third world countries.
The unique feature of this nail is that you can put the nail in without
requiring a fluoroscopy machine.One is
able to do this by reducing the fracture through an open incision.They also have an extra long jig that allows
one to place the distal interlock screws along with several other creative
tools that help to ensure that the distal screw is being successfully inserted
into the nail.Despite the lack of
fluoroscopy the case went surprisingly well and we successfully placed the SIGN
nail in about the same amount of time that it would have take to place an
intramedullary nail in the United States. Following this we did another SIGN nail to fix a closed femur
fracture. We finished in the OR at about 6pm. Therefore, I didn't
have time for much other than eating a little dinner, getting cleaned up, and
relaxing for a few minutes before hitting the sack.

The next day I operated with Dr. Kiprono, who was a young
Kenyan trained orthopedic surgeon in the 1st year of his
practice.Our 1st case was a
SIGN nail on a nonunion of a prior segmental femur fracture.It was rather tricky to find the femoral
canal on both sides of the fracture, but non-the-less we were able to get a
nail successfully placed in a reasonable amount of time.The second case was one that I had never seen
before – a chronic elbow fracture dislocation.Dr. Kiprono let me take the lead operating and I was able to
successfully open reduce the elbow.It
was quite challenging, but also quite rewarding at the same time.Our final case of the day involved pinning an
unstable fracture dislocation of a fourth metatarsal.

While the operating
room conditions were comparable in many ways to the United States, the wards at
Tenwek Hospital were strikingly different. The wards at Tenwek are large
rooms that contain anywhere from 5-25 patients and are separated based on sex
and hospital service. Patient fees for staying in the hospital are
approximately 600 Kenyan shillings or a little over $7 dollars per day, plus
the cost of any medications that they receive. In addition, the hospital
here has moved towards a payment system where patients are expected to make
payment for their surgery prior to any elective procedure - fixing a fracture
is considered elective. For example, a common orthopedic surgery procedure
such as fixing a femur fracture costs $50,000 Kenyan shillings ($570 US
dollars), which is equal to the median monthly post tax income in Kenya.
In comparison to US healthcare this is extraordinarily cheap, but it is a
significant amount of money for many people in this region of the country.
By charging this fee the hospital is able to stay mostly self
sustainable, and is also to pay the salaries of the 600 local Kenyans that it
employees. Charging a fee also seems to make the patients much more invested
in their care.

During my two week stay at Tenwek Hospital I ended up
performing over 30 cases.I learned a
lot of what it is like to be a missionary surgeon in the third world.I also learned that sometimes you have to
accept different treatment options as good enough based on the resources
available to you.If you are interested in
reading more about my experience I wrote a more extensive blog along with my
personal reflections during the trip that is outside the scope of this
summary.It can be found at http://2013kenyatrip.blogspot.com/2013?m=1

Washington University Orthopaedic Surgery: Resident Travel Blog

Through the mentorship of faculty, our orthopaedic surgery residency program offers a resident trainee the opportunity to design a personalized international experience and participate in the practice of global medicine.